Social Worker-Palliative Care hos SSM Health

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Role Purpose

The Social Worker, Palliative Care who works in collaboration with the Palliative Care Consultative Service Medical Director and other interdisciplinary team members, is accountable for providing and managing the outcomes in the delivery of palliative health care services to patient families. Performs those accountabilities relevant to addressing palliative care, psychosocial concerns of patients and families, discharge planning coordination and community agency referrals. Creates optimal outcomes for the patient and family by managing complex psychosocial and economic co-morbidities. Through advanced practice skills mobilizes resources to reduce risk, and serves as ambassador between hospital and community.

Role Responsibilities

  • MISSION AND VALUES: Be a visible model for the hospital's mission and values. Exhibit the values and philosophy of SSM Health Care and St. Mary's Hospital in daily activities and perform job functions in accordance with hospital policies. Respect the privacy and dignity of individuals, courteously provide them with services and information and recognize the patient care mission of the hospital, it's spiritual heritage, and its overall philosophy.
  • ROLE WITH THE PALLIATIVE CARE TEAM: Participate as an integral member of the team. Represent team on new consults when needed. Promote mutuality of discussion and support among team members. Provide consultation, collaboration, coordination, partnership on the team's work with patients, families and staff. Participate in daily discussion with team members regarding changes in plan of care and symptomatology. ROLE WITH PATIENTS AND FAMILIES: Provide a bio-psycho social assessment and clinical social work counseling interventions regarding: (1) Mental health issues (mood disorders, anxiety disorders, personality disorders) (2) Symptom management through complementary therapies (3) Adjustment to diagnosis, prognosis, treatment and end of life decisions (4) Assess and provide counseling regarding the psychosocial needs of involved children; direct intervention with children. Collaborate with team, patient, family, and staff in ensuring communication to facilitate patient/family abilities to make informed choices. Attend and participate in family conferences and pre-post conferences. Participates in family meetings and plan of care meetings. Advocate for patients and families to ensure their wishes, questions and concerns are heard. Ensure bereavement follow-up with high-risk families following the death of a patient for whom the team has provided care. Assess, discuss and provide information to patient/family/staff about hospice/TLC home care options for discharge during family meetings and palliative care consultation. This includes presenting basic information about hospice benefit and services. ROLE WITH PALLIATIVE CARE PROGRAM: Promote the PC Team (inpatient, clinic, and TLC home care). Consultation regarding role of Social Work on PC team. Identify opportunities for improving Palliative Care at St. Mary's Hospital. ROLE WITH MEDICAL CENTER STAFF: Consultation, coordination, collaboration, education with primary care teams including Care Coordinators, Social Workers, Medical Residents, Fellows, Attendings, Bedside Nurses, etc. Promote PC Team. Support and reinforce that PC is a consult service. The team does not assume primary care of patient. ROLE WITH UNIT/PROGRAM SOCIAL WORKER: Make contact with the Unit/Program Social Workers and/or Care Coordinator following PC Team's receipt of referral. Elicit background information through chart and/or communication. Collaborate and clarify role between unit and palliative care Social Worker. Provide consultation regarding discharge planning to primary team. Referrals to post discharge services are the responsibility of the Unit Social Worker and/or Care Coordinator. Maintain regular communication with the Unit Social Workers and/or Care Coordinator. ROLE WITH THE PC CLINIC: Provide psychosocial assessment and clinical social work interventions to patient and family. Provide consultation, collaboration, and coordination with PC clinical physician. Provide community resource linkage as appropriate. Provide information about hospice resources and services including the Medicare Hospice benefit.
  • CUSTOMER RELATIONS: Consistent with the hospital vision to surpass the expectations of those who depend on us, the Social Worker demonstrate a customer focus while providing service (e.g. maintain confidentiality, is courteous to all customers patients, families and all other hospital staff- addresses and follow up on departmental customer concerns). Provide excellent customer services. Know and practice hospital identified customer service behaviors. Identify responsiveness to customer needs as a personal priority.
  • QUALITY: Support the importance of Continuous Quality Improvement. Participate in department quality improvement projects. Participate in hospital wide interdisciplinary quality improvement projects, as needed. Make suggestions for continuous improvement in departmental procedures and processes specific to PM/Night role.
  • HUMAN: SELF DEVELOPMENT: Be a self-learner and foster learning in others. Pursue continuing education in area of expertise/leadership. Achieve and maintain hospital wide and department identified competencies. Participate in education offers provided by the hospital. Attend all mandatory training programs. DEPARTMENTAL STAFF MEETINGS/SHARED GOVERNANCE COUNCILS: Actively participate in departmental staff meetings. Participate in shared accountability and decision-making. Provide input into departmental Shared Governance Councils. POLICY & PROCEDURES: comply with hospital and departmental policies and procedures. Comply with all quality and regulatory standards. RECOGNITION & SUPPORT: Recognize value and build on differences and commonalities in people. Recognize, acknowledge and support the contributions of all co-workers. OTHER: participate in education and training of social work students and new department employees as needed. Maintain and update resource files. Provide ongoing education regarding resources and the continuum of care to patients, families, and clinical staff. Maintain work area in a clean and orderly manner. Perform other duties as requested.
  • TEAMWORK: Recognize and value contributions of co-workers. Participate in team conferences and "huddles". Work with staff to enhance the appropriate flow of patients through the system. Use team process and consensus building for decision-making. Act with integrity and honesty, being willing to trust others and able to engender trust.
  • PLANNING: Projects, department activities and programs are based on SSMHC/WI strategic plan. Participate in identifying new department opportunities that contribute to the strategic plan and departmental goals. Participate in the department process for accomplishing and measuring outcomes.
  • FISCAL: Effectively manages work hours to stay within budgeted FTE hours.
  • Other duties as required.


Minimum Qualifications

  • Master's degree in Social Work from an accredited school.
  • State of Wisconsin Licensed Clinical Social Work
  • Health care law and regulations related to acute care and the immediate post-acute continuum.
  • Computer skills. Psychosocial assessment, risk factor analysis, and discharge planning.

Preferred Qualifications

  • Previous experience in Palliative Care
  • Previous medical social work in an acute care setting.

Department Specific

Must have knowledge and skill of social work theory and practice as it pertains to patients of all ages. Must be able to utilize social work practice skills. Must be skilled in establishing and maintaining effective interpersonal relationships with patients of all ages. Must be skilled in linking patients and families to appropriate resources. Must be able to communicate well, both verbally and in writing. Sufficient medical knowledge to effectively evaluate medical records. Must have the ability to work collaboratively with the medical staff and peers. Must be organized and able to work independently

St. Mary's Hospital – Madison –

St. Mary's is a 440-bed tertiary referral hospital offering inpatient and outpatient treatment and diagnostic services in primary care and nearly all specialties. Medical/surgical areas of special focus include the Family Birth Center, pediatrics, Neuroscience Center, geriatrics, orthopedics, emergency services and more. St. Mary's is affiliated with the University of Wisconsin School of Medicine's three-year family practice residency program. Since 1912, St. Mary's has provided service to much of south-central Wisconsin including Dane County and 17 other nearby counties. In the growing city of Sun Prairie, northeast of Madison, St. Mary's Emergency Clinic provides services to more than 30,000 residents.

Primary Location

Wisconsin-Madison-SSM Health St. Mary's Hospital - Madison
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